(RN) Manager, Utilization Management - 136750

The Manager of Utilization Management supervises Nurse Case Manager and Referral Coordinator staff responsible for Managed Care Utilization Management (UM) following regulatory and compliance as it relates to delegation for commercial and seniors attributed members under UC San Diego Health IPA for our HMO Health Plans.

Key Responsibilities:

• Oversees and coordinates day to day department operations, schedules staff to ensure adequate coverage, prioritizes UM team workload and assignments, covers team member duties as needed, resolves system issues, advises on work methods, functions as a resource and assists with prior authorizations and Inpatient UR/ Discharge planning and escalates complex cases as needed for Medical Director review or Assistant Director UM/ Director of PHSO.
• Coordinates and/or leads case management teams with a variety of clinical and nonclinical staff to review specific routine, expedited and complex cases, optimize house guidelines and scope of practice, and evaluate options for quality and efficiency along the referral determination process.
• Collects, analyzes, and reports data on UM processes and results, including in network vendor relationships and adequacy, referrals, resource management, and regulatory compliance.
• Collaborates with management on operational and performance issues and the development of new processes and programs to improve UM systems and processes.
• Coaches and evaluates team members and participates in decision-making on hiring, salary actions, terminations, performance ratings, and other human resources matters.
• Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
• Ensures adequate orientation, training, and mentoring of new staff. Keeps staff and patient care teams informed of changes and updates in processes, technology, regulations, and quality standards. Provides guidance and instructions on UM updates to processes, procedures and clinical guidelines/policies.
• Implements new methods, systems, and processes.
• Other duties as assigned.

• Bachelor's degree in nursing.
• Registered Nurse in the state of California.
• Five or more years of relevant experience.
• Experience must include 3-5 years of experience in a direct supervisory/managerial role within IPA/MSO or Health Plan/HMO. Experience with Commercial and Medicare lines of business.
• Strong hands-on experience with prior authorization review process.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals and grievances.
• Experience and proven success in ability to effectively supervise a team and to manage the complex workflow and multiple priorities.
• Must have excellent skills to communicate and influence effectively with all levels of staff, physicians, patients and external constituents, both verbally and in writing.
• Solid technology skills with ease of use of all programs (such as EPC, mcg) and an ability to prioritize multiple tasks in a fast-paced environment.

• Previous UM experience working for an IPA/MSO or Health Plan/HMO in a managerial/supervisor role
• Thorough understanding of Health Plan delegation, financial responsibility and medical necessity for referral processing using evidenced-based tools.

• Employment is subject to a criminal background check and pre-employment physical.
• Must be able to work various hours and locations based on business needs. Availability weekend/holidays as needed
• Hybrid Schedule: The candidate selected will work in the office 1-2 days per week once you complete initial orientation. Additional onsite days may be required based on department and business needs.

If employed by the University of California, you will be required to comply with our Policy on Vaccination Programs, which may be amended or revised from time to time. Federal, state, or local public health directives may impose additional requirements.

If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

For the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.